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Now if you're in healthcare, you've probably gone

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through all kinds of basic science training. And

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during that time, you learned a ton of

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diseases and microbiology and a lot of things

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that sounded the same. When I

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was studying for my first exam, which was called

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the USMLE Step 1, I remember

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waking up in the middle of the

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night and trying to remember the differences

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between miparidine and morphine and other different

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medications that started with the letter M.

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Obviously, I was dealing with some anxiety about

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the test. But so many things sound

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the same. So much so that

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our electronic medical records have warnings to

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make sure we're ordering the right medications.

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And so I noticed this week that I

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had some patients with some conditions that

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they thought was one thing, but it turned out

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to be another. And those all have

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to do with some dermatologic conditions known

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as herpetic wittelow, herpangina, and

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hand, foot, and mouth disease. These three

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conditions get mixed up a lot by people. They

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all kind of sound the same because they have

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the same letter H. But let's go

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through them so that when your patients present

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out with them, you can help alleviate some

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of their anxieties and help them understand what's

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going on. I'm Dr. Nikhil Sanpal, your friendly

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neighborhood internist and gastroenterologist, and we're basically going

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to be doing it like Sesame Street.

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This week's letter, the letter H. Now

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our first condition this week is a

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skin condition known as herpetic wittelow. And

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it's a viral infection, and yes, the

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herpetic term is accurate because it's caused

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by herpes simplex one or two. Now

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it actually affects young children very commonly under the age

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of 10. And then of course

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adults who may have come in contact with those children

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who were in their 20s, 30s, and

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40s. Herpetic wittelow is primarily

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caused by HSV1 in children, but

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an adult can be either one

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or two. And how does it

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spread? Well, it turns out it's

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direct contact with those secretions. The

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lot of times patients themselves me and

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come in contact with children you see

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a lot of health care workers who

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work in pediatrics or who work in

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childcare centers for may have children who

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are and is symptomatic carriers or may

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have some lesions get spread through direct

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digital contact with these mansions. And

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so what does that look like? While prophetic when

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Low is exactly what you think it's

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a cluster of the schools or even

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a single mystical itself. But here's what's

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weird. Business. Circles themselves typically

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only are on the fingers and

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the facts either the tips of

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the digits, the actual pulp of the

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digits or can even be along with

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some or first index finger. Now for

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most patients these lesions usually appear in

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about to the fifteen days basically couple

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weeks after inoculation and usually they'll

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have those vessels that appear. Some patients

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may even have some tingling in burning

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as this is affecting the nerve tissue

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in that area. Some patients may have

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some be symptoms like flu. Like illness

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and seaver. But more often than not,

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the blisters and vessels are the primary

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findings. Now the. Of thing

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the patients may describes he is that

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if these blisters rupture, they may have

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some sort of sarah singleness or even

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non puerile and fluid released and the

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tissue itself looks kind of like a

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honeycomb. This is basically diagnostic for her

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pet acquittal. Oh, and the diagnosis itself

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is one hundred percent clinical. You.

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Could do an old school test like a

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zinc smear with that kind of been retired.

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We don't really do that anymore, primarily into

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a viral culture which is the most sensitive,

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but again, some patients totally like that because

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it requires one to four days for positive

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results and more often than not, it doesn't

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really change management. The. Reason why

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is because the cheap enough for pedic with

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alone is just conservative. it's gonna go away

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and two to four weeks and the most

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patients will just tell him to put some

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ice on it and rest the hands of

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a taxi. Painful but to keep their hands

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clean and dry and try a present for

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the transmission of infection especially if them open

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lesions or actual vesicles that leaking and that

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case and we probably recommend some tried pressing.

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Now. I'm a common question that I get asked

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on rounds. It's for these patients who have

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for pedic with alone do we do anything about

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it? Can we use a cycle of your

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medications? The. Answer is we don't really

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know. There isn't a lot of data. Yes,

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There is some possibility that giving these

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medications while their approach almost symptoms can

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actually certain the duration of symptoms and

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prevent for the viral setting. So then

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why did I just say it's conservative?

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It turns out some evidence is there

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for oral antiviral therapy in patients who

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have prophetic little plus other primary hs

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the infection sites or if they're having

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for current up adequate alone assistant getting

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better in that case giving them a

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cycle of your can be helpful. Now.

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The next condition that comes up with

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an H is gonna be one that

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the board exams love and it's basically

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a skin infection that goes along with

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herpes that occurs on the face, neck,

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and arms. But. Why is such a

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board favorite? Because. It's a very common

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amongst wrestlers and rugby players and the

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reason why. Are. One of the may

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have this the secular a partial rash

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and when they get in close contact

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with one another through their sporting events,

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they actually end up having it exposed

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to. When that happens, it spreads during

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matches spell lot of times the wrestlers

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or rugby players don't realize that they

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have herpes. clearly a torah which actually

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gets misdiagnosed. as for which latest or

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even at times they think they have.

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And to tiger now why is the

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com Gladly it's harm, the gladiators fight

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and sort of the wrestlers. Sometimes his

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name's pretty awesome, but the condition itself

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fucks and. so for this again treatments

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conservative and very similar to her pet

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acquittal no one condition that masquerades like

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for panic with low or even herpes

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that he a term is going to

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simply be decide sonic eczema to the

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very common looking thing that occurs and

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people with very dry skin and it

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looks like actual vesicles but it's not

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and suspect commonly misdiagnosed another a topic

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dermatitis that occurs and patience with hs

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to eat is known as eggs them

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propelled them as also formerly called capo

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c marisela form corruption It's very

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commonly seen on the boards and sometimes

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obviously in real life conditions as well

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in patients who are immunosuppressive agents to

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help control some kind of primary dermatologic

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condition. So as you can see,

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there's all kinds of things that happen with the

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letter H and very easy to confuse them. It's

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not as easy to confuse Q, which

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is basically the James Bond character who's

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the head of research and development and

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makes all the cool over-the-top inventions like

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pens that blow up and, you know,

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Rolex watches with laser beams in them.

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But of course I digress. Now

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our last two H's are very commonly

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mistaken. Hand, foot, and mouth disease and

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heart bandgina. And they occur in kids,

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but they can happen in adults as

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well. In fact, we're moving into

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the season in which you may see a lot

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of hand, foot, and mouth disease and heart bandgina.

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They typically occur in the summer and early autumn.

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Part of this might just because kids are playing

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outside and part of this has to do with

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the viral transmission timelines. Now how does it

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get spread? Well both of them

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are typically spread worse than a person

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through either transmission by oral or respiratory

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secretions. So who's causing these

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viral infections in the summer months when

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we should be playing outside? Well hand,

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foot, and mouth disease is primarily caused

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by enterovirus, while heart bandgina is primarily

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caused by cocsacki viruses. So

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if these are different viruses, why are they

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so commonly confused? It turns out that they

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both have oral lesions in the mouth. But

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let's go over each one individually to see

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how they differ. You see,

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typical hand, foot, and mouth disease has these

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painful lesions on the tongue and the buccal

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mucosa. Sometimes they're so painful

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they can't even eat or have any oral intake.

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And they'll also have a macular,

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popular, or even vesicular rash on

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the hands, feet, buttocks, and extremities.

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That's why you can see it kind of all goes together

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with our topic of H. In fact, I'm

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going to title this Beware of H. Why

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not? Now cocsacki, hand,

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foot, and mouth disease also causes

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high fevers. The vesicular

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bullus lesions can actually cause

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ulcerations, palmar desclamations, and even

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nail distribution. So it can be very

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very severe and of course there can

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be fevers as well So the kids

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will be very very irritable which makes

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it very difficult for kids because it's

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painful now This is in stark contrast

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to herpanjina You want to think of

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herpanjina as oral lesions on the tonsils

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soft palate and high fevers It can

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also be associated with loss of appetite

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and vomiting, but those are primarily the

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things So how do you tell

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them apart? You're not going to have a rash

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with herpanjina Hand, foot and mouth

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disease has that macular popular rash and if

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it's really severe with coccyx A6 They

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can have a vesicular bullish rash as well So

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why am I being so deliberate about which

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one has oral lesions? Where are they and

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who has a rash? Because the diagnosis of

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both hand, foot and mouth disease and herpanjina

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is made clinically First you're gonna look at

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the oral enanthem in other words Where are

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the lesions in the mouth and second you're

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gonna look for that viral exanthem And that's

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really all there is to get the diagnosis.

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How do you treat them? Well, they're both

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basically treated the same way most Uncomplicated

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cases of hand, foot and mouth in

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herpanjina resolved within about a week The

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management is pretty supportive you can treat the

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pain that the kids have with ibuprofen or

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acetaminophen And you might be wondering

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well, what about adults? It turns out adults can

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get hand, foot and mouth disease Rare

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for them to develop herpanjina But it's primarily

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from probably taking care of their kids or

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someone else's kids in the workplace Who already

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have hand, foot and mouth disease and

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with that ladies and gentlemen brings to the

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end of the terrible H's We might pick

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another letter in the future, but that brings

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us to the end of this podcast I'm

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dr. Nikhet Sanpal your friendly namehood internist and

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gastroenterologist. I hope you enjoyed this episode. I'll

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see you next time You